Friday 8 October 2010

MRCP revision battle 27.4: Pancreatitis

Acute pancreatitis tends to present as epigastric/central abdominal pain radiating to the back with vomiting.  The pain may be improved by sitting forward.

Signs may be few; periumbilical discoloration (Cullen's sign) or flank discoloration (Grey Turner's sign) are rare.


Causes of pancreatitis can be remembered by I GET SMASHED:
  • idiopathic
  • gallstones
  • ethanol
  • trauma
  • steroids
  • mump
  • autoimmune
  • scorpion venom
  • hyperlipidaemia, hypercalcaemia, hypothermia
  • ERCP
  • drugs (steroids, ocreotide, sulphonamides, tetracyclines, azathioprine, sodium valproate)

Investigations:
  • bloods including amylase 
    • note amylase normalises in 24-48hrs; serum lipase is more sensitive and specific
  • AXR: ?sentinel loop ?loss of psoas shadow
  • CT abdo is the investigation of choice
  • score using the Modified Glasgow criteria.

Modified Glasgow criteria (helpfully spells out 'pancreas'):
  • Pa O2 <8
  • Age >55
  • Neurophils: WCC >15
  • Calcium: <2
  • Renal function: urea >16
  • enzymes: LDH >600; AST >200
  • Albumin: <32
  • Sugars: glucose >10
3 or more suggests severe pancreatitis.



Management of acute pancreatitis is:
  • lots of IV fluid, catheter for fluid balance
  • analgesia
  • close observation
  • treat cause

Complications of pancreatitis include:
  • early
    • sepsis
    • shock
    • ARDS
    • renal failure
    • DIC
    • hypocalcaemia
    • hyperglycaemia - 5% need insulin
  • late
    • necrosis and pseudocyst (=fluid in lesser sac)
    • abscess
    • fistulae
    • chronic pancreatitis



Now for something completely different, visual field defects...